Parsons Janet A, Yu Catherine H Y, Baker Natalie A, Mamdani Muhammad M, Bhattacharyya Onil, Zwarenstein Merrick, Shah Baiju R
Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.
PLoS One. 2016 Dec 28;11(12):e0167878. doi: 10.1371/journal.pone.0167878. eCollection 2016.
Diabetes is a chronic disease commonly managed by family physicians, with the most prevalent complication being cardiovascular disease (CVD). Clinical practice guidelines have been developed to support clinicians in the care of diabetic patients. We conducted a pragmatic cluster randomized controlled trial (RCT) of a printed educational toolkit aimed at improving CVD management in diabetes in primary care, and found no effect, and indeed, the possibility of some harm. We conducted a qualitative evaluation to study the strategy for guideline implementation employed in this trial, and to understand its effects. This paper focuses solely on the qualitative findings, as the RCT's quantitative results have already been reported elsewhere.
All family practices in the province of Ontario had been randomized to receive the educational toolkit by mail, in either the summer of 2009 (intervention arm) or the spring of 2010 (control arm).A subset of 80 family physicians (representing approximately 10% of the practices randomized and approached, with records on 1,592 randomly selected patients with diabetes at high risk for CVD) then took part in a chart audit and reflective feedback exercise related to their own practice in comparison to the guideline recommendations. They were asked to complete two forms (one pre- and one post-audit) in order to understand their awareness of the guidelines pre-trial, their expectations regarding their individual performance pre-audit, and their reflections on their audit results. In addition, individual interviews with thirteen other family physicians were conducted. Textual data from interview transcripts and written commentary from the pre- and post-audit forms underwent qualitative descriptive analysis to identify common themes and patterns. Analysis revealed four main themes: impressions of the toolkit, awareness was not the issue, 'it's not me it's my patients', and chart audit as a more effective intervention than the toolkit. Participants saw neither the toolkit content nor its dissemination strategy to be effective, indicating they perceived themselves to be aware of the guidelines pre-trial. However, their accounts also indicated that they may be struggling to prioritize CVD management in the midst of competing demands for their attention. Upon receiving their chart audit results, many participants expressed surprise that they had not performed better. They reported that the audit results would be an important motivator for behaviour change.
The qualitative findings outlined in this paper offer important insights into why the intervention was not effective. They also demonstrate that physicians have unperceived needs relative to CVD management and that the chart audit served to identify shortcomings in their practice of which they had been hitherto unaware. The findings also indicate that new methods of intervention development and implementation should be explored. This is important given the high prevalence of diabetes worldwide; appropriate CVD management is critical to addressing the morbidity and mortality associated with the disease.
糖尿病是一种常见的慢性病，通常由家庭医生进行管理，最常见的并发症是心血管疾病（CVD）。已经制定了临床实践指南以支持临床医生对糖尿病患者的护理。我们针对一个旨在改善初级保健中糖尿病患者心血管疾病管理的印刷教育工具包进行了一项实用的整群随机对照试验（RCT），结果发现没有效果，甚至还存在某种危害的可能性。我们进行了一项定性评估，以研究该试验中采用的指南实施策略，并了解其效果。本文仅关注定性研究结果，因为该RCT的定量结果已在其他地方报道。
安大略省的所有家庭医疗诊所被随机分为两组，一组于2009年夏季通过邮件接收教育工具包（干预组），另一组于2010年春季接收（对照组）。然后，80名家庭医生（约占随机分组并参与研究的诊所的10%，记录了1592名随机选取的具有心血管疾病高风险的糖尿病患者）参与了一项图表审核及与自身实践相关的反思反馈活动，并与指南建议进行比较。他们被要求填写两份表格（一份审核前表格和一份审核后表格），以了解他们在试验前对指南的知晓情况、审核前对个人表现的期望以及对审核结果的反思。此外，还对另外13名家庭医生进行了个人访谈。对访谈记录的文本数据以及审核前后表格中的书面评论进行了定性描述分析，以确定共同的主题和模式。分析揭示了四个主要主题：对工具包的印象、知晓不是问题、“问题不在我，在我的患者”以及图表审核是比工具包更有效的干预措施。参与者认为工具包内容及其传播策略都无效，这表明他们觉得自己在试验前就知晓这些指南。然而，他们的叙述也表明，在需要他们关注的众多事务中，他们可能难以将心血管疾病管理列为优先事项。在收到图表审核结果后，许多参与者对自己之前没有表现得更好表示惊讶。他们表示审核结果将是行为改变的一个重要推动因素。
本文概述的定性研究结果为干预措施无效的原因提供了重要见解。这些结果还表明，医生在心血管疾病管理方面存在未被察觉的需求，图表审核有助于发现他们此前未意识到的实践中的不足之处。研究结果还表明，应探索新的干预措施开发和实施方法。鉴于全球糖尿病的高发病率，这一点很重要；适当的心血管疾病管理对于解决与该疾病相关的发病率和死亡率至关重要。
